Medicare Clinical Review Subject Matter Expert

Location: Baltimore, MD
Analytica is seeking a Medicare Clinical Review Subject Matter Expert to provide subject matter expertise to the program integrity and data analysis staff concerning Medicare Part A & B guidelines and specific plans requirements, as needed.  The Medicare Clinical Review Subject Matter Expert will communicate and present Medicare policy, requirements, and guidelines to stakeholders. 

Primary Responsibilities Include (But Are Not Necessarily Limited To):
  • Maintain a thorough and comprehensive understanding of regulations, policies and procedures related to Medicare Part A & B.
  • Serves as a subject matter expert on Medicare claims policy.
  • Act as a liaison between internal and external customers to resolve systems / process issues.
  • Determine appropriateness and effectiveness of services requested using established medical coverage criteria, guidelines and departmental, policies and procedures.
  • Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions and rationale.
  • Provides Medicare Part A & B subject matter expertise and technical assistance for complex matters. Independently identifies sources of the required information and offers interpretation and insights.
  • Supports investigators and law enforcement in investigation development, Medicare Part A & B policy and fraud trends analysis by offering independent judgment. 
  • Participates in discussions and activities with CMS and plan sponsors concerning Medicare Part A & B policy, clinical questions, and fraud trends
  • Independently develops and delivers internal and external training as assigned by management.

Required Experience / Skills:
  • 10+ years clinical hospital experience with an understanding of ICD-10 coding, 
  • 10+ years insurance experience in utilization review
  • Bachelor’s degree in business, nursing, public health, health science, health promotion or related field or equivalent education and experience. 
  • Certified Professional Coder (CPC) or equivalent coding certification 
  • Registered Nurse or equivalent certification required 
  • Experience working with HCPCS - Healthcare Common Procedure Coding System and/or CPT - Current Procedural Terminology
  • Knowledge of pharmacy benefits operations and management and how they relate to Medicare Parts A & B
  • Knowledge of CMS's annual Part A & B regulatory changes
  • Experience conducting fraud audits of, or for, governmental agencies
  • Understanding the relevant data, and the ability to explain the impact that the data has on Part A & B programs.
  • A broad clinical management and leadership background and demonstrate knowledge of, and proficiency in successfully applying, applicable regulations and guidelines, such as, pharmacy laws and Medicare Part A & B rules and regulations, etc.
  • Experience in reviewing healthcare fraud, utilization, and quality of care issues as they relate to managed care organizations, as well as experience training and managing other registered nurses in performing medical review.
  • ​Ability to review medical records from a program integrity perspective, as well as determine whether appropriate care was provided to Medicare Parts A & B beneficiaries.
  • Demonstrated ability to analyze metrics, summarize key business learnings, and translate into tactical plans. 
  • Excellent verbal and written business communication skills, including the ability to simplify and summarize complex information, and create and deliver professional presentations to senior leadership and external audiences. 
  • Excellent collaboration and relationship management skills, including the ability to work with a wide variety of people and personalities, and effectively facilitate group discussions and decision-making. 
  • Proficiency in Microsoft products such as Word, Excel, Access, and PowerPoint
  • Experience in managed care environment

About ANALYTICA: Analytica is a leading consulting and information technology solutions provider to public sector organizations supporting health, civilian, and national security missions. Founded in 2009 and headquartered in Washington D.C., the company is an established SBA certified HUBZone and 8(a) small business that has been recognized by Inc. Magazine each of the past three years as one of the 250 fastest-growing companies in the U.S.  Analytica specializes in providing software and systems engineering, information management, analytics & visualization, agile project management, and management consulting services. The company is appraised by the Software Engineering Institute (SEI) at CMMI® Maturity Level 3 and is an ISO 9001:2008 certified provider.
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